Chapter 5: Teen Sexuality and Pregnancy

Many teenagers are sexually active. Danice K. Eaton et al. of the Centers for Disease Control and Prevention (CDC) report in “Youth Risk Behavior Surveillance—United States, 2007” (Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf) that 47.8% of high school students surveyed in grades nine through 12 have had sexual intercourse. (See Table 5.1.) Girls (45.9%) were slightly less likely than boys (49.8%) to have had intercourse. African-American students (66.5%) were more likely than Hispanic (52%) or non-Hispanic white students (43.7%) to be sexually active.

The proportion of students who had intercourse rose with age; 32.8% of ninth graders, 43.8% of 10th graders, 55.5% of 11th graders, and 64.6% of 12th graders had ever had intercourse at the time of the survey. (See Table 5.1.) A number of youth were sexually active before age 13; 7.1% had had intercourse at age 12 or younger. This early sexual activity is of concern, especially among young girls. According to studies such as Sonya S. Brady and Bonnie L. Halpern-Felsher's “Adolescents' Reported Consequences of Having Oral Sex versus Vaginal Sex” (Pediatrics, vol. 119, no. 2, February 2007), among sexually active young teens, boys tend to feel good about themselves and experience popularity as a result of sexual activity, whereas girls are more likely to feel used and bad about themselves. In addition, Denise D. Hallfors et al. report in “Which Comes First in Adolescence—Sex and Drugs or Depression?” (American Journal of Preventive Medicine, vol. 29, no. 3, 2005) that being sexually active puts adolescents, particularly girls, at risk for depression.

Risk Factors for Early Sexual Activity

In “Early Adolescent Sexual Activity: A Developmental Study” (Journal of Marriage and the Family, vol. 61, no. 4, November 1999), Les B. Whitbeck et al. note that “the main predictors of early intercourse were age, association with delinquent peers, alcohol use, opportunity, and sexually permissive attitudes.” Cami K. McBride et al. indicate in “Individual and Familial Influences on the Onset of Sexual Intercourse among Urban African American Adolescents” (Journal of Consulting and Clinical Psychology, vol. 71, no. 1, February 2003) that family conflict is also linked to early sexual activity among poor urban African-American adolescents. In “Parental Influences on Adolescent Sexual Behavior in High Poverty Settings” (Archives of Pediatrics and Adolescent Medicine, vol. 53, no. 10, 1999), another study of poor African-American children, Daniel Romer et al. find that those who reported high levels of monitoring from parents were less likely to have sex before adolescence (at age 10 or earlier) and had lower rates of sexual initiation in their teen years as well. John S. Santelli et al. report in “Initiation of Sexual Intercourse among Middle School Adolescents: The Influence of Psychosocial Factors” (Journal of Adolescent Health, vol. 34, no. 3, March 2004), a study of inner-city seventh graders, that peer norms about refraining from sex were strongly correlated with seventh and eighth graders abstaining; on the contrary, drug or alcohol use increased the risk of early sexual activity. Other studies, such as S. Liliana Escobar-Chaves et al.'s “Impact of the Media on Adolescent Sexual Attitudes and Behaviors” (Pediatrics, vol. 116, no. 1, July 2005), find a correlation between exposure to sexual themes in mass media and adolescent sexual activity.

Reasons Given for Not Delaying Sex

A number of studies report that both sexes consider social pressure the major factor in engaging in early sexual activity. Peer pressure and a belief that “everyone is doing it” have often been cited as explanations. However, in “Adolescent Girls' Perceptions of the Timing of Their Sexual Initiation: ‘Too Young’ or ‘Just Right’?” (Journal of Adolescent Health, vol. 34, no. 5, May 2004), Sian Cotton et al. indicate that most female adolescents (78% of the studied group) felt that they had been “too young” at their first sexual experience.

TABLE 5.1 Percentage of high school students who ever had sexual intercourse and who had sexual intercourse for the first time before age 13 years, by sex, race, ethnicity, and grade, 2007

Category

Ever had sexual intercourse

Had first sexual intercourse before age 13 years

Female

Male

Total

Female

Male

Total

%

%

%

%

%

%

*Non-Hispanic.

SOURCE: Danice K. Eaton, “Table 61. Percentage of High School Students Who Ever Had Sexual Intercourse and Who Had Sexual Intercourse for the First Time before Age 13 Years, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,”Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)

Race/ethnicity

White*

43.7

43.6

43.7

3.1

5.7

4.4

Black*

60.9

72.6

66.5

6.9

26.2

16.3

Hispanic

45.8

58.2

52.0

4.5

11.9

8.2

Grade

9

27.4

38.1

32.8

4.9

13.5

9.2

10

41.9

45.6

43.8

4.7

9.1

6.9

11

53.6

57.3

55.5

3.4

9.9

6.6

12

66.2

62.8

64.6

2.4

6.7

4.5

Total

45.9

49.8

47.8

4.0

10.1

7.1

In addition, some research challenges the theory that social pressure is the strongest influence on teenagers' sexual decisions. The press release “Study Offers Parents New Insights into When and Why Teens Choose Drinking, Drugs, and Sex” (October 29, 2002, http://www.sadd.org/teenstoday/teenstodaypdfs/study.pdf) discusses the Teens Today survey, which was commissioned by Students against Destructive Decisions and the Liberty Mutual Group. Students in grades six through 11 were asked what factors had most influenced their decisions about sexuality. The most common reasons 11th graders gave for engaging in sexual activity were boredom, curiosity, and to please one's partner. The most commonly mentioned reasons not to have sex were fear of pregnancy, fear of sexually transmitted diseases (STDs), and not being in a relationship or in love.

The Media and Teen Concepts of Sexuality

In Sex on TV 4 (November 2005, http://www.kff.org/entmedia/upload/Sex-on-TV-4-Full-Report.pdf), the Kaiser Family Foundation and Dale Kunkel et al. of the University of Arizona discuss the results of a study of sexual messages on television. The report finds that the percent of shows with sexual content had increased from 56% in 1998 to 70% in 2005. In addition, in those shows that included sexual content, the number of sexual scenes per hour had risen from 3.2 in 1998 to 5 in 2005—and in the top teen programs, there were on average 6.7 sexual scenes per hour. Of the 20 shows most popular with teenagers, 70% included some sexual content, and 45% included sexual behavior. More than one out of 10 (11%) episodes included scenes in which sexual intercourse was depicted or strongly implied. Only 10% of shows most popular with teens that contained sexual content included a reference to sexual risk or responsibility.

The study's authors note that the portrayal of sex on television does not have wholly negative consequences. In fact, even though references to sexual risk or responsibility are still low, they have increased in recent years. Furthermore, these references can have a big impact. The study's authors state, “New research over the past several years has documented the powerful positive impact television can have on young people—whether it is learning about HIV from an episode of Girlfriends or about condom efficacy from an episode of Friends. Indeed … for many young people, exposure to a higher proportion of shows referencing sexual risks or responsibilities can promote healthier sexual decision-making.”

Sexual Activity and Substance Use

Over the years, a number of studies have suggested a link between substance use and sexual activity. Researchers find that both sexual activity and a history of multiple partners correlate with some use of drugs, alcohol, and cigarettes. However, Eaton et al. indicate that among sexually active students, only 22.5% reported in 2007 they had used alcohol or drugs at the time of their last sexual experience. (See Table 5.2.) Males (27.5%) were more likely than females (17.7%) to report this behavior; African-Americans (16.4%) were less likely than Hispanics (21.4%) or non-Hispanic whites (24.8%) to report using alcohol or drugs during sexual activity.

Jie Guo et al. of the University of Washington note in “Developmental Relationships between Adolescent Substance Use and Risky Sexual Behavior in Young Adulthood” (Journal of Adolescent Health, vol. 31, no. 4, 2002) that there is a link between adolescent binge drinking and marijuana use and risky sexual behavior. Young people

TABLE 5.2 Percentage of high school students who drank alcohol or used drugs before last sexual intercourse and who were ever taught in school about AIDS or HIV, by sex, race, ethnicity, and grade, 2007

Category

Drank alcohol or used drugs before last sexual intercourse

Were taught in school about AIDS or HIV infection

Female

Male

Total

Female

Male

Total

%

%

%

%

%

%

*Non-Hispanic

Note: Among the 35.0% of students nationwide who were currently sexually active.

SOURCE: Danice K. Eaton, “Table 67. Percentage of High School Students Who Drank Alcohol or Used Drugs before Last Sexual Intercourse and Who Were Ever Taught in School about Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) Infection, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,”Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)

Race/ethnicity

White*

19.8

30.5

24.8

91.7

90.5

91.1

Black*

12.9

19.8

16.4

91.8

88.8

90.3

Hispanic

16.5

25.9

21.4

84.8

85.1

85.0

Grade

9

20.4

22.9

21.8

87.7

86.4

87.1

10

20.0

27.4

23.6

90.3

89.2

89.7

11

14.8

28.3

21.6

92.6

91.0

91.8

12

17.3

29.1

22.6

90.9

89.1

90.0

Total

17.7

27.5

22.5

90.2

88.7

89.5

who used marijuana or binge drank in high school were more likely at age 21 to have had more sexual partners and to use condoms inconsistently. In “Trends in Sexual Risk Behavior and Unprotected Sex among High School Students, 1991–2006: The Role of Substance Use” (Journal of School Health, vol. 78, no. 11, November 2008), John E. Anderson and Trisha E. Mueller of the CDC find that adolescents who use drugs or alcohol are more likely to engage in risky sexual behaviors. The researchers report, “In spite of favorable trends in recent years for both sexual risk and drug use among adolescents, the [Youth Risk Behavior Survey] data show that a high percentage of youth are at risk and that many youth remain at dual risk from substance abuse and sexual behaviors.”

Voluntary and Nonvoluntary Experiences

The 1995 and 2002 National Survey of Family Growth asked women whether their first sexual experience was voluntary. In “A Demographic Portrait of Statutory Rape” (2005, http://www.childtrends.org/Files/ConferenceonSexualExploitationofTeensPresentation.pdf), Kristin Moore and Jennifer Manlove find that 18% of girls whose first sexual experience occurred at age 13 or under said it was non-voluntary, compared to 10% of 15- and 16-year-olds and 5% of 17- and 19-year-olds. In addition, Elizabeth Terry-Humen, Jennifer Manlove, and Sarah Cottingham report in “Trends and Recent Estimates: Sexual Activity among U.S. Teens” (June 2006, http://www.childtrends.org/Files//Child_Trends-2006_06_01_RB_SexualActivity.pdf) that survey respondents were asked to state which of three statements most closely described how much they wanted their first sexual intercourse experience: “I really didn't want it to happen at the time,”“I had mixed feelings—part of me wanted it to happen at the time and part of me didn't,” and “I really wanted it to happen at the time.” Only 34% of adolescent females said they really wanted it to happen at the time, compared to 62% of adolescent males who felt that way. More than one out of 10 (13%) females, compared to 6% of males, reported that they really did not want their first sexual intercourse to happen at that time.

Saewyc, Magee, and Pettingell indicate that teenage pregnancy is also strongly linked to sexual abuse.

According to Child Trends, a nonprofit research organization dedicated to improving the lives of children, early sexual initiation for teenage girls has been linked to several adverse outcomes. The Child Trends publication Facts at a Glance (January 1, 1997) indicates that more than half (54%) of females 14 or younger at first sexual intercourse reported experiencing nonvoluntary sex at some point during their teen years. Brent C. Miller, Bruce H. Monson, and Maria C. Norton report in “The Effects of Forced Sexual Intercourse on White Female Adolescents” (Child Abuse and Neglect, vol. 19, no. 10, October 1995) that early sexual initiation has also been linked to domestic violence and verbal abuse later in life and to depression and low self-esteem. In “Associations of Dating Violence Victimization with Lifetime Participation, Co-occurrence, and Early Initiation of Risk Behaviors among U.S. High School Students” (Journal of Interpersonal Violence, vol. 22, no. 5, May 2007), Danice K. Eaton et al. of the CDC link early sexual intercourse with dating violence victimization among female students. Erin Schelar, Suzanne Ryan, and Jennifer Manlove argue in “Long-Term Consequences for Teens with Older Sexual Partners” (April 2008, http://www.childtrends.org/Files//Child_Trends-2008_05_06_FS_OlderPartners.pdf) that many girls with an early sexual initiation have partners three or more years older; the combination of early sexual initiation with older sexual partners puts girls at a higher risk for contracting STDs. In “Long-Term Health Correlates of Timing of Sexual Debut: Results from a National U.S. Study” (American Journal of Public Health, vol. 98, no. 1, January 2008), Theo G. M. Sandfort et al. link early sexual initiation to increased sexual risk behaviors and problems and sexual functioning for both males and females.

Too Few Use Contraceptives

Eaton et al. find that in 2007, 61.5% of sexually active teenagers reported that they or their partners used condoms during their last sexual intercourse. (See Table 5.3.) Young African-Americans reported the highest condom use (67.3%) among sexually active youth, Hispanic students reported a rate of 61.4%, and non-Hispanic white students reported the lowest rate of 59.7%. Males (68.5%) were significantly more likely than females (54.9%) to report condom use. However, the use of condoms decreased from the ninth grade (69.3%) to the 12th grade (54.2%), a period during which the frequency of sexual intercourse increased, probably because older adolescents turned to alternative methods of birth control, such as oral contraception.

Among sexually active students nationwide in 2007, 16% reported they or their partners used oral contraceptives, or “the pill.” (See Table 5.3.) Even though this form of contraception protects against pregnancy, it does not protect against STDs. Twice as many non-Hispanic white students (20.8%) reported using birth control pills than did Hispanic (9.1%) or African-American students (9.1%). This disparity may be due to the need for a prescription for birth control pills; white students tend to have greater access to medical care than minority students do. Birth control pill use increased between ninth (8.7%) and 12th grade (23.5%).

TABLE 5.3 Percentage of high school students who used a condom during last sexual intercourse and who used birth control pills before last sexual intercourse, by sex, race, ethnicity, and grade, 2007

Category

Condom use

Birth control pill use

Female

Male

Total

Female

Male

Total

%

%

%

%

%

%

*Non-Hispanic.

Notes: Among the 35.0% of students nationwide who were currently sexually active. Birth control pills used to prevent pregnancy.

SOURCE: Danice K. Eaton et al., “Table 65. Percentage of High School Students Who Used a Condom during Last Sexual Intercourse and Who Used Birth Control Pills before Last Sexual Intercourse, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,”Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)

Race/ethnicity

White*

53.9

66.4

59.7

24.0

17.0

20.8

Black*

60.1

74.0

67.3

12.1

6.3

9.1

Hispanic

52.1

69.9

61.4

9.1

9.0

9.1

Grade

9

61.0

75.8

69.3

9.2

8.3

8.7

10

59.5

73.2

66.1

13.7

9.5

11.6

11

55.1

69.3

62.0

18.9

11.0

15.0

12

49.9

59.6

54.2

25.6

20.8

23.5

Total

54.9

68.5

61.5

18.7

13.1

16.0

Drawing on a national survey of male adolescents, Erum Ikramullah and Jennifer Manlove find in “Condom Use and Consistency among Teen Males” (October 2008, http://www.childtrends.org/Files/Child_Trends-2008_10_30_FS_CondomUse.pdf) that even though 71% of male teens reported using a condom the first and most recent time they had sexual intercourse, only half of male teens reported consistent condom use with their most recent sexual partner.

REASONS FOR USE OR NONUSE OF CONDOMS. There are many factors involved in adolescents' decisions to use or not use condoms. The November 2000 SexSmarts (http://www.kff.org/entpartnerships/upload/SexSmarts-Survey-Safer-Sex-Condoms-and-the-Pill-Toplines.pdf), a survey of 519 adolescents aged 12 to 17 by the Henry J. Kaiser Family Foundation and Seventeen magazine, highlights teens' fairly casual attitude toward condom use. The survey shows that teens do not completely understand the importance of using condoms consistently to avoid STDs, including HIV and acquired immunodeficiency syndrome (AIDS). Eleven percent agreed with the statement “having sex without a condom every now and then is not that big of a deal,” and 9% believed that “if you don't have a lot of partners you don't need to use condoms.” One out of four (25%) teenage females agreed with the statement “condoms break so often they are not worth using.” In “Gender Roles” (November 2002, http://www.kff.org/entpartnerships/upload/Gender-Rolls-Summary.pdf), a follow-up survey, SexSmarts finds that girls face more negative attitudes than boys do if they carry condoms with them; 70% of boys and 75% of girls agreed with the statement, “If a girl carries a condom people might think she is ‘easy’,” whereas only 43% of boys and 36% of girls agreed with the statement, “If a boy carries a condom people might think he is ‘easy’.”

Research indicates that adolescents' attitudes and beliefs about their relationships with their partners influence whether or not they will use condoms. Celia M. Lescano et al. of Brown Medical School find in “Condom Use with ‘Casual’ and ‘Main’ Partners: What's in a Name?” (Journal of Adolescent Health, vol. 39, no. 3, September 2006) that adolescents were more likely to use a condom with a partner that they perceived as a casual one. However, even when partners were casual ones, teens reported using condoms only about half the time. Therefore, teens were not adequately protecting themselves against STDs even with partners they perceived as more risky. Condom use with partners perceived as main partners was even lower. Lescano et al. state, “Perhaps adolescents overestimate the safety of using condoms ‘most of the time’ with a casual partner and underestimate the risk of unprotected sex with a ‘serious’ partner.”

Cynthia Grossman et al. find in “Adolescent Sexual Risk: Factors Predicting Condom Use across the Stages of Change” (AIDS and Behavior, vol. 12, no. 6, November 2008) that teens who consistently used condoms reported a greater understanding of the importance of using condoms, had better communication about condom use with their partners, and were less likely to perceive themselves as immune to the human immunodeficiency virus (HIV) than their peers who reported inconsistent condom use.

In “Condom Use among High-Risk Adolescents: Anticipation of Partner Disapproval and Less Pleasure Associated with Not Using Condoms” (Public Health Reports, vol. 123, no. 5, September–October 2008), Larry K. Brown et al. note that they surveyed 1,410 adolescents and young adults between the ages of 15 and 21 who had unprotected sex in the previous 90 days. The researchers find that nearly two-thirds of adolescents did not use condoms at the time of last intercourse. Teens who did not use condoms were significantly more likely to believe that condoms reduce sexual pleasure. They were also less likely to discuss condom use with their partners, but were more concerned that their partners would not approve of condom use.

According to Tricia Hall et al., in “Attitudes toward Using Condoms and Condom Use: Differences between Sexually Abused and Nonabused African American Female Adolescents” (Behavioral Medicine, vol. 34, no. 2, Summer 2008), there is some evidence that teens who have been sexually abused are less likely to use condoms and more likely to have unprotected sex than their nonabused peers.

Adolescents and young adults have a higher risk of acquiring STDs than older adults. Female adolescents may have an increased susceptibility to chlamydia, a bacterial infection that can cause pelvic inflammatory disease and is a contributing factor in the transmission of HIV. In Child Health USA 2007 (2008, ftp://ftp.hrsa.gov/mchb/chusa_07/c07.pdf), the Maternal and Child Health Bureau states that in 2005 chlamydia was the most common STD among adolescents. It was also more common in adolescents and young adults than in any other age group, with 1,621 cases among every 100,000 teens aged 15 to 19. This group also had the highest rates of gonorrhea infection. As Figure 5.1 shows, non-Hispanic African-American teens had much higher rates of both chlamydia and gonorrhea than non-Hispanic white teens.

Kathleen J. Sikkema et al. emphasize in “HIV Risk Behavior among Ethnically Diverse Adolescents Living in Low-Income Housing Developments” (Journal of Adolescent Health, vol. 35, no. 2, August 2004) that half of all new HIV infections in the United States are diagnosed in people under 25 years old. Most of these young people become infected through sexual activity. The researchers find that the risk of HIV infection was highest among older adolescents who did not see a need to practice safer sex because they were with steady partners and among teens who abused drugs and alcohol. Sikkema et al. suggest that their

study results could be used to design prevention programs for those adolescents most at risk.

In “Does Parental Involvement Predict New Sexually Transmitted Diseases in Female Adolescents?” (Archives of Pediatrics and Adolescent Medicine, vol. 158, no. 7, July 2004), Julie A. Bettinger et al. test whether parental involvement had any impact on the rates of STDs among low-income African-American adolescent girls. The researchers find that when these high-risk teens perceived their parents as exercising a high degree of supervision over their activities, they had lower rates of both gonorrhea and chlamydia infection. Anne M. Teitelman, Sarah J. Ratcliffe, and Julie A. Cederbaum find in “Parent-Adolescent Communication about Sexual Pressure, Maternal Norms about Relationship Power, and STI/HIV Protective Behaviors of Minority Urban Girls” (American Psychiatric Nurses Association Journal, vol. 14, no. 1, 2008) that racial and ethnic minority adolescent females who communicated with their parents about sex were better able to be consistent in condom use.

Human Papilloma Virus Vaccine

One STD, the human papilloma virus (HPV), can cause genital warts and cervical cancer in women. At least half of sexually active people will get HPV; most of the time, it resolves on its own. However, sometimes it lingers and causes cell changes that can lead to cervical cancer. In “What Are the Key Statistics about Cervical Cancer?” (March 26, 2008, http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_cervical_cancer_8.asp), the American Cancer Society estimates that in 2008

about 11,070 women will be diagnosed with cervical cancer, and about 3,870 women will die from it. A large proportion of cervical cancer cases are caused by HPV, perhaps in combination with other factors. Clinical trials for a new vaccine against certain strains of the virus, given in three doses over a six-month period, show that the vaccine is nearly 100% effective. In August 2006 the CDC recommended in “HPV Vaccine Information for Young Women” (http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm) that the new vaccine be given to girls before they become sexually active, around age 12, to prevent the transmission of HPV.

However, such recommendations stirred up controversy, which heated up in February 2007, when Rick Perry (1950–), the governor of Texas, issued an executive order making the state the first to require that girls entering the sixth grade be vaccinated as a condition for enrolling in public school. Liz Austin Peterson reports in “Texas Gov. Orders Anti-cancer Vaccine” (Associated Press, February 2, 2007) that conservative groups feared that such a requirement undermined abstinence education and would condone premarital sex. In “Virginity or Death!” (Nation, May 12, 2005), Katha Pollitt explains that others argued for mandatory vaccination because young girls would not abstain from sexual activity due to fear of cervical cancer, HPV cannot be prevented by condom use, and 70% of cases of cervical cancer could be prevented by this vaccine.

Brady E. Hamilton, Joyce A. Martin, and Stephanie J. Ventura of the CDC report in “Births: Preliminary Data for 2006” (National Vital Statistics Reports, vol. 56, no. 7, December 5, 2007, http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_07.pdf) that birthrates for women aged 15 to 19 rose in 2006 for the first time in many years. (See Figure 5.2.) Among girls aged 15 to 17, the birthrate dropped from 38.6 per 1,000 women in 1991 to 21.4 per 1,000 women in 2005, but rose to 22 births per 1,000 women in 2006. Among young women aged 18 to 19 years, the birthrate dropped from 94 per 1,000 in 1991 to 69.9 in 2005, but rose to 73 births per 1,000 in 2006. Most teens who give birth are unmarried. (See Table 5.4.) Childbearing by unmarried women jumped to record high levels that year, to 1.6 million births.

According to Hamilton, Martin, and Ventura, available data by race show that the greatest percentage increase in teen births in 2006 was among African-Americans, whose rate rose 5% to 63.7 births per 1,000. Births to Native American teens increased 4% to 54.7 per 1,000, 3% for non-Hispanic white teenagers to 26.6 births per 1,000, and 2% for Hispanic teens to 83 births per 1,000. The only ethnic group whose birthrate did not see an increase was Asian and Pacific Islanders. In “Births: Final Data for 2006” (National Vital Statistics Reports, vol. 57, no. 7, January 7, 2009), Joyce A. Martin et al. of the CDC explain

Consequences for Teen Mothers and Their Children

Teenage mothers and their babies face more health risks than older women and their children. Teenagers who become pregnant are more likely than older women to suffer from pregnancy-induced hypertension and eclampsia (a life-threatening condition that sometimes results in convulsions and/or coma). Teenagers are more likely to have their labor induced, and an immature pelvis can cause prolonged or difficult labor, possibly resulting in bladder or bowel damage to the mother, infant brain damage, or even death of the mother and/or the child.

Even though most health risks are similar for children born to teenage and older mothers, teenage mothers may have a higher prevalence of certain risk factors. For example, the CDC notes in Health, United States, 2007 (2007, http://www.cdc.gov/nchs/data/hus/hus07.pdf) that in 2004 teenagers had very high rates of smoking during pregnancy (10.5% for 15- to 17-year-olds and 16% for 18- to 19-year-olds) and that smokers were nearly twice as likely to have low-birth-weight babies as nonsmokers. In the fact sheet “Preventing Infant Mortality” (January 13, 2006, http://www.hhs.gov/news/factsheet/infant.html), the U.S. Department of Health and

TABLE 5.4 Births to unmarried women, by age, 2005 and 2006

[Data for 2006 are based on a continuous file of records received from the states. Figures for 2006 are based on weighted data rounded to the nearest individual, so categories may not add to totals]

Human Services indicates that teenagers in general are at a higher risk of having low-birth-weight babies. Michael Klitsch finds in “Youngest Mothers' Infants Have Greatly Elevated Risk of Dying by Age One” (Perspectives on Sexual and Reproductive Health, vol. 35, no. 1, January–February 2003) that babies born to adolescents have a greater risk of dying between one and 12 months after birth.

Few teenage mothers are ready for the emotional, psychological, and financial responsibilities and challenges of parenthood. Becoming a parent at a young age usually cuts short a teenage mother's education, limiting her ability to support herself and her child. According to Sandra L. Hofferth, Lori Reid, and Frank L. Mott, in “The Effects of Early Childbearing on Schooling over Time” (Family Planning Perspectives, vol. 33, no. 6, November–December 2001), women who gave birth as teens in the early 1990s had only a 65% probability of graduating from high school, and only a 29% probability of completing some college. David M. Fergusson, Joseph M. Boden, and L. John Horwood report in “Abortion among Young Women and Subsequent Life Outcomes” (Perspectives on Sexual and Reproductive Health, vol. 39, no. 1, March 2007) that educational attainment is lower among teen mothers than among teens who had an abortion. Additionally, Susheela Singh et al. note in “Socioeconomic Disadvantage and Adolescent Women's Sexual and Reproductive Behavior: The Case of Five Developed Countries” (Family Planning Perspectives, vol. 33, no. 5, November–December 2001) that 40% of American women aged 20 to 24 who gave birth before age 20 had an income of less than 149% of the federal poverty guideline.

The children of teen mothers face consequences as well. In Playing Catch-up: How Children Born to Teen Mothers Fare (January 2005, http://www.teenpregnancy.org/works/pdf/PlayingCatchUp.pdf), Elizabeth Terry-Humen, Jennifer Manlove, and Kristin A. Moore examine data on kindergarteners to determine the relationship between the age a woman has a child and how her child does in several key areas: cognition and knowledge, language and communication skills, approaches to learning, emotional well-being and social skills, and physical well-being and motor development. The researchers find that children born to mothers aged 17 and younger had lower general knowledge scores and language and communication skills, compared to children born to mothers aged 20 and older. Children's approaches to learning, physical well-being, and emotional development, as well as their social skills and emotional well-being, were relatively unaffected by maternal age. In sum, Terry-Humen, Manlove, and Moore state, “Children born to mothers aged 17 and younger began kindergarten with lower levels of school readiness.… The children born to mothers in their 20s clearly outperformed those whose mothers were still teenagers at time of birth, and the most consistent and pronounced differences were observed when comparing children born to mothers aged 17 and younger to those children born to mothers aged 22–29.”

Greg Pogarsky, Terence P. Thornberry, and Alan J. Lizotte come to similar conclusions in “Developmental Outcomes for Children of Young Mothers” (Journal of Marriage and Family, vol. 68, no. 2, May 2006). The researchers note that boys born to young mothers had elevated risks of drug use, gang membership, unemployment, and early parenthood, whereas girls had elevated risks of becoming young mothers themselves.

Adolescent Fathers

According to the Child Trends Databank, in Teen Births (January 2007, http://www.childtrendsdatabank.org/pdf/13_PDF.pdf), in 2005 15- to 19-year-old males had a birthrate

of 16.8 per 1,000, down from a high of 24.7 in 1991. This rate was substantially lower than the 2005 rate for teenage girls of 40.5 per 1,000. The rate was higher for African-American male teens (32.2) than for white male teens (14.2); data for Hispanic male teens were unavailable. The difference between male adolescent and female adolescent birthrates is due in part to the fact that many teen mothers have older partners, as well as to the underreporting of information about fathers on birth certificates. In Facts at a Glance (November 2003, http://www.childtrends.org/Files/FAAG2003.pdf), Child Trends reports that 38% of births to mothers aged 18 and younger were to fathers four or more years older than the mother. In some cases teen mothers have been sexually abused by their older partners.

Such studies alert officials who design programs for the prevention of pregnancy and STDs to the need to pay attention not only to preadolescent and adolescent males but also to older males who are partners of teenage girls. Because these men are typically out of the public school system, officials agree that programs must be broader in scope.

The CDC reports that in 2004, 839,000 abortions were performed; the year before, 848,000 had been performed. (See Table 5.5.) The Guttmacher Institute conducted a survey and estimated that a much higher number of abortions had been performed in 2004—over 1.2 million. The rate of abortions per 100 live births has decreased from a high of 35.9 in 1980 to 23.8 in 2004. Girls under 15 years old had the highest rate of abortions (76.2 per 100 live births) in 2004, followed by teens aged 15 to 19 (36.2 per 100 live births). All other age groups had lower rates of abortion. For all age groups, African-Americans had the highest abortion rate of any race or ethnic group (47.2 per 100 live births), followed by Hispanics (21.1 per 100 live births) and non-Hispanic whites (16.1 per 100 live births).

[Data are based on reporting by state health departments and by hospitals and other medical facilities]

—Data not available.

aIn 1998 and 1999, Alaska, California, New Hampshire, and Oklahoma did not report abortion data to CDC. For comparison, in 1997, the 48 corresponding reporting areas reported about 900,000 legal abortions.

bIn 2000, 2001, and 2002, Alaska, California, and New Hampshire did not report abortion data to CDC.

cIn 2003 and 2004, California, New Hampshire, and West Virginia did not report abortion data to CDC.

dNo surveys were conducted in 1983, 1986, 1989, 1990, 1993, 1994, 1997, 1998, 2001, 2002, or 2003. Data for these years were estimated by interpolation.

eFor calculation of ratios by each characteristic, abortions with characteristic unknown were distributed in proportion to abortions with characteristic known.

fFor 1989 and later years, white race includes women of Hispanic ethnicity.

gBefore 1989, black race includes races other than white.

hData from 20–22 states, the District of Columbia (DC), and New York City (NYC) were included in 1991–1993. The number of reporting areas increased to 25 states, DC, and NYC in 1994–2004. States were excluded either because they did not collect data on Hispanic origin or due to incomplete reporting of Hispanic data (greater than 15% unknown Hispanic origin).

iFor 1973–1975, data indicate number of living children.

jFor 1975, data refer to four previous live births, not four or more. For five or more previous live births, the ratio is 47.3.

kFor calculation of percent distribution by each characteristic, abortions with characteristic unknown were excluded.

Notes: The number of areas reporting adequate data (less than or equal to 15% missing) for each characteristic varies from year to year. Data for additional years are available.

SOURCE: “Table 16. Legal Abortions and Legal Abortion Ratios, by Selected Patient Characteristics: United States, Selected Years 1973–2004,” in Health, United States, 2007. With Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, 2007, http://www.cdc.gov/nchs/data/hus/hus07.pdf (accessed September 15, 2008). Nongovernmental data from Guttmacher Institute Abortion Provider Survey; L.B. Finer and S.K. Henshaw, “Abortion Incidence and Services in the United States in 2000,”Perspectives on Sexual and Reproductive Health, vol. 35, no. 1, 2003; L.B. Finer and S.K. Henshaw, Estimates of U.S. Abortion Incidence, 2001–2003, The Alan Guttmacher Institute, August 2006; R.K. Jones et al., “Abortion in the United States: Incidence and Access to Services, 2005,”Perspectives on Sexual and Reproductive Health, vol. 40, no. 1, 2008.

Characteristic

1973

1975

1980

1985

1990

1995

1999a

2000b

2002b

2003c

2004c

Number of legal abortions reported in thousands

Centers for Disease Control and Prevention (CDC)

616

855

1,298

1,329

1,429

1,211

862

857

854

848

839

Guttmacher Instituted

745

1,034

1,554

1,589

1,609

1,359

1,315

1,313

1,293

1,287

1,222

Abortions per 100 live birthse

Total CDC

19.6

27.2

35.9

35.4

34.4

31.1

25.6

24.5

24.6

24.1

23.8

Age

Under 15 years

123.7

119.3

139.7

137.6

81.8

66.4

70.9

70.8

75.3

83.0

76.2

15–19 years

53.9

54.2

71.4

68.8

51.1

39.9

37.5

36.1

36.8

37.4

36.2

20–24 years

29.4

28.9

39.5

38.6

37.8

34.8

31.6

30.0

30.3

30.0

29.1

25–29 years

20.7

19.2

23.7

21.7

21.8

22.0

20.8

19.8

20.0

19.5

19.1

30–34 years

28.0

25.0

23.7

19.9

19.0

16.4

15.2

14.5

14.8

14.4

14.3

35–39 years

45.1

42.2

41.0

33.6

27.3

22.3

19.3

18.1

18.0

17.3

17.0

40 years and over

68.4

66.8

80.7

62.3

50.6

38.5

32.9

30.1

31.0

29.3

28.6

Race

Whitef

32.6

27.7

33.2

27.7

25.8

20.3

17.7

16.7

16.4

16.5

16.1

Black or African Americang

42.0

47.6

54.3

47.2

53.7

53.1

52.9

50.3

49.5

49.1

47.2

Hispanic originh

Hispanic or Latina

—

—

—

—

—

27.1

26.1

22.5

23.3

22.8

21.1

Not Hispanic or Latina

—

—

—

—

—

27.9

25.2

23.3

23.7

23.4

23.6

Marital status

Married

7.6

9.6

10.5

8.0

8.7

7.6

7.0

6.5

6.5

6.3

6.1

Unmarried

139.8

161.0

147.6

117.4

86.3

64.5

60.4

57.0

57.0

53.8

51.0

Previous live birthsi

0

43.7

38.4

45.7

45.1

36.0

28.6

24.3

22.6

23.3

22.7

23.0

1

23.5

22.0

20.2

21.6

22.7

22.0

20.6

19.4

19.4

19.0

19.0

2

36.8

36.8

29.5

29.9

31.5

30.6

29.0

27.4

27.9

27.1

26.4

3

46.9

47.7

29.8

18.2

30.1

30.7

29.8

28.5

29.1

28.3

27.4

4 or morej

44.7

43.5

24.3

21.5

26.6

23.7

24.2

23.7

23.6

23.4

22.9

Percent distributionk

Total

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

Period of gestation

Under 9 weeks

36.1

44.6

51.7

50.3

51.6

54.0

57.6

58.1

60.5

60.5

61.4

9–10 weeks

29.4

28.4

26.2

26.6

25.3

23.1

20.2

19.8

18.4

18.0

17.6

11–12 weeks

17.9

14.9

12.2

12.5

11.7

10.9

10.2

10.2

9.6

9.7

9.3

13–15 weeks

6.9

5.0

5.1

5.9

6.4

6.3

6.2

6.2

6.0

6.2

6.3

16–20 weeks

8.0

6.1

3.9

3.9

4.0

4.3

4.3

4.3

4.1

4.2

4.0

21 weeks and over

1.7

1.0

0.9

0.8

1.0

1.4

1.5

1.4

1.4

1.4

1.4

Previous induced abortions

0

—

81.9

67.6

60.1

57.1

55.1

53.7

54.7

55.3

55.3

55.0

1

—

14.9

23.5

25.7

26.9

26.9

27.1

26.4

25.8

25.7

25.8

2

—

2.5

6.6

9.8

10.1

10.9

11.5

11.3

11.3

11.2

11.3

3 or more

—

0.7

2.3

4.4

5.9

7.1

7.7

7.6

7.6

7.8

7.9

As Table 5.5 shows, the abortion rates for teens have declined dramatically since the late 1980s, as have the pregnancy and birthrates.

States have varying laws on parental involvement in minors' abortion decisions. In “An Overview of Abortion Laws” (January 1, 2009, http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf), the Guttmacher Institute reports that 16 states and the District of Columbia required no parental involvement in minors' abortions. Thirty-four states required some parental involvement, 22 required parental consent, and 10 required parental notification.

In Just the Facts about Sexual Orientation and Youth (2008, http://www.apa.org/pi/lgbc/publications/justthefacts.pdf), a pamphlet for school personnel, the American Psychological Association (APA) stresses that sexual orientation is one aspect of the identity of adolescents—not a mental disorder. According to the APA, sexual orientation is developed across a lifetime and along a continuum; in other words, teens are not necessarily simply homosexual or heterosexual, but may feel varying degrees of attraction to people of both genders. The APA explains that gay, lesbian, and bisexual adolescents face prejudice and discrimination that negatively affect their educational experiences and emotional and physical health. Their legitimate fear of being hurt as a result of disclosing their sexuality often leads to a feeling of isolation. All these factors account for lesbian, gay, and bisexual adolescents' higher rates of emotional distress, suicide attempts, risky sexual behavior, and substance use. The APA underscores the need for school personnel to be as open and accepting as possible to support these adolescents.

Abstinence

In response to the growing concern about out-of-wedlock births and the threat of AIDS, several national youth organizations and religious groups began campaigns in the early and mid-1990s to encourage teens to sign an abstinence pledge—a promise to abstain from sexual activity until marriage. According to the National Institutes of Health, in the news release “Virginity Pledge Helps Teens Delay Sexual Activity” (January 5, 2001, http://www.nichd.nih.gov/news/releases/virginity.cfm), 2.5 million teens had taken the “virginity pledge” by 1995. Debra Hauser of Advocates for Youth indicates in Five Years of Abstinence-Only-until-Marriage Education: Assessing the Impact (2004, http://www.advocatesforyouth.org/publications/stateevaluations.pdf) that in 1996 the federal government committed $250 million over the following five years to fund state initiatives to promote abstinence as Title V of the Social Security Act. Even though only 11 states made the results of their evaluations of the effectiveness of these programs public, Hauser states that Advocates for Youth examined these evaluations and found that the programs “showed few short-term benefits and no lasting, positive impact.… No program was able to demonstrate a positive impact on sexual behavior over time.”

The administration of U.S. president George W. Bush (1946-) placed a new emphasis on abstinence among teens. According to the White House report Working toward Independence (February 2002, http://www.whitehouse.gov/news/releases/2002/02/welfare-reform-announcement-book.pdf), an overview of Bush's suggested plan for welfare reform, “the goal of Federal policy should be to emphasize abstinence as the only certain way to avoid both unintended pregnancies and STDs.” In 2007, the U.S. government provided $176 million for abstinence-only programs, but no federal funding for comprehensive sex education programs. Title V, the state abstinence-only education program, provided states with federal funding for abstinence-only sex education programs, but in 2007, 25 of 50 states refused to take the money because they did not want to offer such programs.

Despite the federal funds spent on such programs, Eaton et al. find that in 2007 over one-third (35%) of high school students were sexually active at the time of the survey—35.6% of females and 34.3% of males. Younger students were less likely to be currently sexually active than were older students. Even though 47.8% of all students had ever had sexual intercourse; 64.6% of high school seniors had. (See Table 5.1.)

In this context, abstinence-only education will do little to prevent teen pregnancy or the spread of STDs. As John S. Santelli et al. state in “Abstinence and Abstinence-Only Education: A Review of U.S. Policies and Programs” (Journal of Adolescent Health, vol. 38, no. 1, January 2006), “Although abstinence is a healthy behavioral option for teens, abstinence as a sole option for adolescents is scientifically and ethically problematic.… We believe that abstinence-only education programs, as defined by federal funding requirements, are morally problematic, by withholding information and promoting questionable and inaccurate opinions. Abstinence-only programs threaten fundamental human rights to health, information, and life.”

In 2007, the Department of Health and Human Services released Impacts of Four Title V, Section 510 Abstinence Education Programs (April 2007, http://aspe.hhs.gov/hsp/abstinence07/report.pdf) by Christopher Trenholm et al. The researchers conclude that the youth in the abstinence-only programs were no more likely than youth who were assigned to the control group to have abstained from sex. Those who reported having sex had similar numbers of sexual partners and had initiated sex at the same mean age. In September 2008, several articles about abstinence-only programs were published in a special issue of the journal Sexuality Research and Social Policy (vol. 5, no. 3). Douglas B. Kirby states in “The Impact of Abstinence and Comprehensive Sex and STD/HIV Education Programs on Adolescent Sexual Behavior” that such programs fail to change sexual behavior in teenagers. Other articles concluded that the programs provide inaccurate information about condoms and that they violate human rights principles.

The fate of abstinence-only education was unknown when Barack Obama (1961–) was sworn in as president of the United States in January 2009. Many considered Obama to be in favor of more comprehensive sex education programs. The HHS states in Budget in Brief, Fiscal Year 2009 (2008, http://www.hhs.gov/budget/09budget/2009BudgetInBrief.pdf) that in fiscal year 2009, $191 million in grant money was available for abstinence education, up $28 million from the previous year. The White House explains in A New Era of Responsibility: Renewing America's Promise (2009, http://www.whitehouse.gov/omb/assets/fy2010_new_era/A_New_Era_of_Responsibility2.pdf) that President Obama's 2010 budget proposal not only continued funding for abstinence education but also provided funding for “medically-accurate and age-appropriate information to youth who have already become sexually active,” signaling a potential change of direction in the new administration.

Sex and STD/HIV Education in Schools

As of November 2008, 35 states and the District of Columbia required schools to provide education on HIV/AIDS and other STDs, although in all cases parents were allowed to remove their children from sex education classes. (See Table 5.6.) Twenty-six states required schools to stress the importance of abstinence in STD and HIV/AIDS education, and 11 states required abstinence to be covered. Seventeen states required schools to teach students about contraception, but none required that it be stressed.

According to Eaton et al., 89.5% of all students had been taught about AIDS or HIV in school, compared to 91.5% in 1997. (See Table 5.2.) As HIV/AIDS is increasingly common among young people, the declining percentages of students who learn about the disease in school is problematic.

TABLE 5.6 Sex and STD/HIV education policy by state, November 2008

State

Sex education

STI/HIV education

Parental role

Mandated

If taught, content required

Mandated

If taught, content required

Consent required

Opt-out permitted

Abstinence

Contraception

Abstinence

Contraception

aParents' removal of student must be based on religious or moral beliefs.

bIn AZ, MT, NY and PA, opt-out is only permitted for STI education, including instruction on HIV; in AZ, parental consent is required only for sex education.

cIL has a broad set of laws mandating general health education, including abstinence; a more specific second law requires a school district that provides sex education to stress abstinence and to provide statistics on the efficacy of condoms as HIV/STI prevention.

dLocalities may override state requirements for sex education topics, including abstinence; state prohibits including material that “contradicts the required components.”

eAbstinence is taught within state-mandated character education.

fState prohibits teachers from responding to students' spontaneous questions in ways that conflict with the law's requirements.

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Teen Sexuality and Pregnancy

Chapter 5Teen Sexuality and Pregnancy

EARLY SEXUAL ACTIVITY

Many teenagers are sexually active. The Centers for Disease Control and Prevention (CDC) reports that in 2005 almost half of high school students (46.8%) had had sexual intercourse, down from the 54.1% who were reported as sexually active in 1991. (See Table 5.1.) One out of seven (14.3%) had had sex with four or more partners. Girls (45.7%) were slightly less likely than boys (47.9%) to have had intercourse. African-American students (67.6%) were more likely than Hispanic (51%) or non-Hispanic white students (43%) to be sexually active.

The proportion of students who had intercourse rose with age; 34.3% of ninth graders, 42.8% of tenth graders, 51.4% of eleventh graders, and 63.1% of twelfth graders had ever had intercourse at the time of the survey. (See Table 5.1.) A number of youth were sexually active before age thirteen; 6.2% had had intercourse at age twelve or younger. This early sexual activity is of concern, especially among young girls. Sonya S. Brady and Bonnie L. Halpern-Felsher of the University of California at San Francisco, in "Adolescents' Reported Consequences of Having Oral Sex versus Vaginal Sex" (Pediatrics, February 2007), find that among sexually active young teens, boys tend to feel good about themselves and experience popularity as a result of sexual activity, whereas girls are more likely to feel bad about themselves as well as feeling used. In addition, the article "Risky Adolescent Behavior Leads to Depression, Not Vice Versa" (NeuroPsychiatry Reviews, December 2005) notes that being sexually active puts adolescents, particularly girls, at risk for depression.

Risk Factors for Early Sexual Activity

In "Early Adolescent Sexual Activity: A Developmental Study" (Journal of Marriage and the Family, November 1999), Les B. Whitbeck et al. note that "the main predictors of early intercourse were age, association with delinquent peers, alcohol use, opportunity, and sexually permissive attitudes." Cami K. McBride et al. of the University of Illinois, in "Individual and Familial Influences on the Onset of Sexual Intercourse among Urban African American Adolescents" (Journal of Consulting and Clinical Psychology, February 2003), indicate that family conflict can also be linked to early sexual activity among poor urban African-American adolescents. In "Parental Influences on Adolescent Sexual Behavior in High Poverty Settings" (Archives of Pediatrics and Adolescent Medicine, 1999), another study of poor African-American children, Daniel Romer et al. of the University of Pennsylvania find that those who reported high levels of monitoring from parents were less likely to have sex before adolescence (at age ten or earlier) and had lower rates of sexual initiation in their teen years as well. John S. Santelli et al., in "Initiation of Sexual Intercourse among Middle School Adolescents: The Influence of Psychosocial Factors" (Journal of Adolescent Health, March 2004), a study of inner-city seventh graders, report that peer norms about refraining from sex were strongly correlated with seventh and eighth graders abstaining; on the contrary, drug or alcohol use increased the risk of early sexual activity.

Reasons Given for Not Delaying Sex

A number of studies report that both sexes consider social pressure the major factor in engaging in early sexual activity. Peer pressure and a belief that "everyone is doing it" are often cited as explanations. However, in "Adolescent Girls' Perceptions of the Timing of Their Sexual Initiation: 'Too Young' or 'Just Right'?" (Journal of Adolescent Health, May 2004), Sian Cotton et al. of the Children's Hospital Medical Center in Cincinnati, Ohio, indicate that most female adolescents (78% of the studied group) felt that they had been "too young" at their first sexual experience.

In addition, recent research challenges the theory that social pressure is the strongest influence on teenagers'

TABLE 5.1

Percentage of high school students who engaged in sexual behaviors and who used a condom and birth control pills, by sex, race/ethnicity, and grade, 2005

Category

Ever had sexual intercourse

Had first sexual intercourse before age 13 years

Had sexual intercourse with ≤4 persons during their life

Currently sexually activeb

Condom usec

Birth control pill used

Female

Male

Total

Female

Male

Total

Female

Male

Total

Female

Male

Total

Female

Male

Total

Female

Male

Total

aNon-Hispanic.

bHad sexual intercourse with ≤1 person during the 3 months preceding the survey.

cAmong the 33.9% of students nationwide who were currently sexually active.

dTo prevent pregnancy.

Source: Adapted from "Table 44. Percentage of High School Students Who Engaged in Sexual Behaviors, by Sex, Race/Ethnicity, and Grade," and "Table 46. Percentage of High School Students Who Were Currently Sexually Active, Who Used a Condom during Last Sexual Intercourse, and Who Used Birth Control Pills before Last Sexual Intercourse, by Sex, Race/Ethnicity, and Grade," in "Youth Risk Behavior Surveillance—United States, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf (accessed February 25, 2007)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

Race/ethnicity

Whitea

43.7

42.2

43.0

2.9

5.0

4.0

11.1

11.6

11.4

33.5

30.6

32.0

55.6

70.1

62.6

27.1

17.2

22.3

Blacka

61.2

74.6

67.6

7.1

26.8

16.5

18.6

38.7

28.2

43.8

51.3

47.4

62.1

75.5

68.9

10.7

9.4

10.0

Hispanic

44.4

57.6

51.0

3.6

11.1

7.3

10.4

21.7

15.9

33.7

36.3

35.0

49.8

65.3

57.7

9.4

10.3

9.8

Grade

9

29.3

39.3

34.3

5.4

12.0

8.7

5.7

13.2

9.4

19.5

24.5

21.9

71.5

77.1

74.5

8.8

6.4

7.5

10

44.0

41.5

42.8

4.1

7.7

5.9

9.7

13.2

11.5

31.1

27.2

29.2

57.1

74.4

65.3

18.0

10.3

14.3

11

52.1

50.6

51.4

2.6

8.0

5.2

14.2

18.1

16.2

40.8

37.9

39.4

57.8

66.0

61.7

20.2

16.6

18.5

12

62.4

63.8

63.1

2.0

6.2

4.1

20.2

22.6

21.4

51.7

47.0

49.4

46.1

65.8

55.4

28.9

21.9

25.6

Total

45.7

47.9

46.8

3.7

8.8

6.2

12.0

16.5

14.3

34.6

33.3

33.9

55.9

70.0

62.8

20.6

14.6

17.6

sexual decisions. In Teens Today (October 29, 2002, http://www.sadd.org/teenstoday/teenstodaypdfs/study.pdf), a survey commissioned by Students Against Destructive Decisions and the Liberty Mutual Group, students in grades six through twelve were asked what factors had most influenced their decisions about sexuality. The most common reasons teenagers gave for engaging in sexual activity were boredom, curiosity, and to please one's partner. The most commonly mentioned reasons not to have sex were fear of pregnancy, fear of sexually transmitted diseases (STDs), and not being in a relationship or in love.

Media and Teen Concepts of Sexuality

In Sex on TV 4 (November 2005, http://www.kff.org/entmedia/upload/Sex-on-TV-4-Executive-Summary.pdf), the Kaiser Family Foundation and Dale Kunkel et al. of the University of Arizona report the results of the latest biennial study of sexual messages on television. The report finds that the percent of shows with sexual content had increased from 56% in 1998 to 70% in 2005. In addition, in those shows that included sexual content, the number of sexual scenes per hour had risen from 3.2 in 1998 to 5 in 2005—and in the top teen programs, there were on average 6.7 sexual scenes per hour. Of the twenty shows most popular with teenagers, 70% included some sexual content, and 45% included sexual behavior. More than one out of ten episodes (11%) included scenes in which sexual intercourse was depicted or strongly implied. Only one out of ten shows most popular with teens that contained sexual content included a reference to sexual risk or responsibility.

The study's authors note that the portrayal of sex on television does not have wholly negative consequences.
In fact, even though references to sexual risk or responsibility are still low, they have increased in recent years, and these references can have a big impact. The study's authors state, "New research over the past several years has documented the powerful positive impact television can have on young people—whether it is learning about HIV from an episode of Girlfriends or about condom efficacy from an episode of Friends. Indeed … for many young people, exposure to a higher proportion of shows referencing sexual risks or responsibilities can promote healthier decision-making."

TABLE 5.2

Percentage of high school students who drank alcohol or used drugs before last sexual intercourse, who were taught about AIDS/HIV in school, and who had been tested for HIV, by sex, race/ethnicity, and grade, 2005

Category

Alcohol or drug use before last sexual intercoursea

Taught in school about AIDS or HIV infection

Tested for HIV

Female

Male

Total

Female

Male

Total

Female

Male

Total

aAmong the 33.9% of students nationwide who were currently sexually active.

bNon-Hispanic.

Source: "Table 48. Percentage of High School Students Who Drank Alcohol or Used Drugs before Last Sexual Intercourse, Were Ever Taught in School about Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) Infection, and Who Were Tested for HIV, by Sex, Race/Ethnicity, and Grade," in "Youth Risk Behavior Surveillance—United States, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf (accessed February 25, 2007)

%

%

%

%

%

%

%

%

%

Race/ethnicity

Whiteb

20.5

29.9

25.0

90.1

88.7

89.4

11.6

8.8

10.2

Blackb

12.8

15.4

14.1

87.2

85.4

86.3

24.1

17.9

21.0

Hispanic

18.7

32.2

25.6

85.8

83.6

84.7

11.2

12.7

12.0

Grade

9

22.7

29.0

26.2

85.5

84.4

85.0

7.9

9.8

8.9

10

18.9

23.6

21.1

89.4

87.3

88.4

13.2

10.2

11.6

11

16.8

29.0

22.5

89.7

89.5

89.6

14.1

10.2

12.2

12

19.2

27.6

23.1

90.1

88.7

89.4

19.3

12.3

15.8

Total

19.0

27.6

23.3

88.5

87.2

87.9

13.2

10.6

11.9

Sexual Activity and Substance Use

Over the years, a number of studies have suggested a link between substance use and sexual activity. Researchers find that both sexual activity and a history of multiple partners correlate with some use of drugs, alcohol, and cigarettes. However, the CDC finds that among sexually active students in 2005, only one-fourth (23.3%) reported they had used alcohol or drugs at the time of their last sexual experience. (See Table 5.2.) Males (27.6%) were more likely than females (19%) to report this behavior; African-Americans (14.1%) were less likely than Hispanics (25.6%) or non-Hispanic whites (25%) to report using alcohol or drugs during sexual activity.

In "Developmental Relationships between Adolescent Substance Use and Risky Sexual Behavior in Young Adulthood" (Journal of Adolescent Health, October 2002), Jie Guo et al. of the University of Washington note a link between adolescent binge drinking and marijuana use and risky sexual behavior. Young people who used marijuana or binge drank in high school are more
likely at age twenty-one to have more sexual partners and to use condoms inconsistently.

The Kaiser Family Foundation, in Substance Abuse and Risky Sexual Behavior (February 2002, http://www.kff.org/youthhivstds/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14907), reports on a survey of almost a thousand teens and young adults from November 2001 through January 2002. More than a quarter (29%) of sexually active fifteen- to seventeen-year-olds surveyed said that alcohol or drugs had influenced their sexual decisions. More than one out of ten (12%) sexually active fifteen- to seventeen-year-olds reported having had unprotected sex while under the influence of drugs or alcohol. Two out of five of these (41%) said their peers drank or used drugs before having sex "a lot" of the time.

Voluntary and Nonvoluntary Experiences

The 1995 and 2002 National Survey of Family Growth asked women whether their first sexual experience was voluntary. In "A Demographic Portrait of Statutory Rape" (2005, http://www.childtrends.org/Files/ConferenceonSexualExploitationofTeensPresentation.pdf), Kristin Moore and Jennifer Manlove find that 18% of girls whose first sexual experience occurred at age thirteen or under said it was nonvoluntary, compared with 10% of fifteen- and sixteen-year-olds and 5% of seventeen- to nineteen-year-olds. In addition, Elizabeth Terry-Humen, Jennifer Manlove, and Sarah Cottingham report in "Trends and Recent Estimates: Sexual Activity among U.S. Teens" (June 2006, http://www.childtrends.org/Files//Child_Trends-2006_06_01_RB_SexualActivity.pdf) that they asked survey respondents to state which of three statements most closely described how much they wanted their first sexual intercourse experience: "I really didn't want it to happen at the time," "I had mixed feelings—part of me wanted it to happen at the time and part of me didn't," and "I really wanted it to happen at the time." Only 34% of adolescent females said they really wanted it to happen at the time, compared with 62% of adolescent males who felt that way. More than one out of ten (13%) females, compared with 6% of males, reported that they really did not want their first sexual intercourse to happen at that time.

Additionally, Anita Raj et al. of Boston University find in "The Relationship between Sexual Abuse and Sexual Risk among High School Students: Findings from the 1997 Massachusetts Youth Risk Behavior Survey" (Maternal and Child Health Journal, June 2000), a study of four thousand high school students, that almost a third of the girls (30.2%) and a tenth of the boys (9.3%) reported having been sexually abused. Sexually abused females were twice as likely to engage in early sexual intercourse and other risky sexual behaviors than girls who had not been abused. Elizabeth M. Saewyc, Lara Leanne Magee, and Sandra E. Pettingell corroborate in "Teenage Pregnancy and Associated Risk Behaviors among Sexually Abused Adolescents" (Perspectives on Sexual and Reproductive Health, May-June 2004) evidence of the increased sexual risks taken by sexually abused youth.

Moreover, according to Child Trends, a nonprofit research organization dedicated to improving the lives of children, early sexual initiation for teenage girls has been linked to a higher risk of becoming the victim of rape or sexual assault at some later time during their adolescence. The Child Trends publication Facts at a Glance 1997 (January 1, 1997) indicates that more than half (54%) of females age fourteen or younger at first sexual intercourse reported experiencing nonvoluntary sex at some point during their teen years. Vaughn I. Rickert et al. note, in "The Relationship among Demographics, Reproductive Characteristics, and Intimate Partner Violence" (American Journal of Obstetrics and Gynecology, October 2002), that early sexual initiation is linked to domestic violence and verbal abuse later in life. Furthermore, in "The Effects of Forced Sexual Intercourse on White Female Adolescents" (Child Abuse and Neglect, October 1995), Brent C. Miller, Bruce H. Monson, and Maria C. Norton of Utah State University find that early sexual initiation can lead to depression and low self-esteem.

CONTRACEPTIVE USE

Too Few Use Contraceptives

The CDC finds that in 2005, 62.8% of sexually active teenagers reported that they or their partners used condoms during their last sexual intercourse, up from 46.2% in 1991, when the CDC began tracking condom use. (See Table 5.1.) Young African-Americans reported the highest condom use (68.9%) among sexually active youth. Hispanic students reported the lowest rate of condom use (57.7%). Males (70%) were significantly more likely than females (55.9%) to report condom use. However, the use of condoms decreased from the ninth grade (74.5%) to the twelfth grade (55.4%), a period during which the frequency of sexual intercourse increased, probably because older adolescents turned to alternative methods of birth control, such as oral contraception.

Among sexually active students nationwide in 2005, 17.6% reported they or their partners used oral contraceptives, or "the pill." (See Table 5.1.) Even though this form of contraception protects against pregnancy, it does not protect against STDs. More white students (22.3%) reported using birth control pills than either Hispanic (9.8%) or African-American students (10%). This disparity may be because of the need for a prescription for birth control pills; white students tend to have greater access to medical care than minority students do. Birth control pill
use increased between the ninth (7.5%) and twelfth grades (25.6%).

REASONS FOR USE OR NONUSE

Research indicates that adolescents' attitudes and beliefs about their relationships with their partners influence whether they will use condoms. Celia M. Lescano et al. find, in "Condom Use with 'Casual' and 'Main' Partners: What's in a Name?" (Journal of Adolescent Health, 2006), that adolescents are more likely to use a condom with a partner that they perceive as a casual one. However, even when partners are casual ones, teens report using condoms only about half the time; therefore, teens are not adequately protecting themselves against STDs, even with partners they perceive as more risky. Condom use with partners perceived as main partners is even lower. Lescano et al. state, "Perhaps adolescents overestimate the safety of using condoms 'most of the time' with a casual partner and underestimate the risk of unprotected sex with a 'serious' partner."

The November 2000 Sexsmart (http://www.kff.org/entpartnerships/upload/SexSmarts-Survey-Safer-Sex-Condoms-and-the-Pill-Toplines.pdf), a survey of 519 adolescents aged twelve to seventeen by the Henry J. Kaiser Family Foundation and Seventeen magazine, also highlights teens' fairly casual attitude toward condom use. The survey shows that teens do not completely understand the importance of using condoms consistently to avoid STDs, including the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS). Eleven percent agreed with the statement "having sex without a condom every now and then is not that big of a deal," and 9% believed that "if you don't have a lot of partners you don't need to use condoms." One out of four teenage females (25%) agreed with the statement "condoms break so often they are not worth using."

SEXUALLY TRANSMITTED DISEASES

Adolescents and young adults have a higher risk of acquiring STDs than older adults. Female adolescents may have an increased susceptibility to chlamydia, a bacterial infection that can cause pelvic inflammatory disease and is a contributing factor in the transmission of HIV. In 2003 chlamydia was the most common STD among adolescents. According to the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services (HHS), in Child Health USA 2005 (2005, http://www.mchb.hrsa.gov/mchirc/chusa_05/pages/pdf/c05.pdf), it was also more common in adolescents than in any other age group, with 1,524 cases among every 100,000 fifteen- to nineteen-year-old girls. This group also had the highest rate of gonorrhea infection, at 443 per 100,000. Syphilis was far less common in teens, with only 1.6 cases per 100,000 reported in 2003. As Figure 5.1 shows, African-American non-Hispanic teens had much higher rates of STDs than non-Hispanic white teens.

The study "HIV Risk Behavior among Ethnically Diverse Adolescents Living in Low-Income Housing Developments" (Journal of Adolescent Health, August 2004) by Kathleen J. Sikkema et al. of Yale University emphasizes that half of all new HIV infections in the United States are diagnosed in people under twenty-five years old. Most of these young people become infected through sexual activity. Sikkema et al. find that the risk of HIV infection was highest among older adolescents who did not see a need to practice safer sex because they were with steady partners and among teens who abused drugs and alcohol. The researchers suggest that study results could be used to design prevention programs for those adolescents most at risk.

Furthermore, Julie A. Bettinger et al., in "Does Parental Involvement Predict New Sexually Transmitted Diseases in Female Adolescents?" (Archives of Pediatrics and Adolescent Medicine, 2004), examine whether parental involvement had any impact on rates of STDs among low-income African-American adolescent girls. They find that when these high-risk teens perceived their parents as exercising a high degree of supervision over their activities, they had lower rates of both gonorrhea and chlamydia infection.

HPV Vaccine

One STD, the human papillomavirus (HPV), can cause genital warts and cervical cancer in women. At least half of sexually active people will get HPV; most of the time, it resolves on its own. However, sometimes it lingers and causes cell changes that can lead to cervical cancer. The American Cancer Society estimates in Cancer Facts and Figures 2005 (http://www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf) that in 2005, 10,370 women were diagnosed with cervical cancer and 3,710 died from it. In "HPV Vaccine Questions and Answers" (August 2006, http://www.cdc.gov/std/hpv/hpv-vaccine.pdf), the CDC's Advisory Committee on Immunization Practices states that up to 70% of these cases are caused by HPV. Clinical trials for a new vaccine against certain strains of the virus, given in three doses over a six-month period, show that the vaccine was nearly 100% effective. The advisory committee recommends that the new vaccine be given to girls before they become sexually active, at around age twelve, to prevent the transmission of HPV.

However, such recommendations stirred up controversy, which heated up in February 2007 when Rick Perry, the governor of Texas, issued an executive order making the state the first to require that girls entering the sixth grade be vaccinated as a condition for enrolling in public school. Conservative groups feared that such a requirement undermined abstinence education and would condone premarital sex. Others argued for mandatory vaccination because young girls would not abstain from sexual activity due to fear of cervical cancer; HPV cannot be prevented by condom use; and 70% of cases of cervical cancer could be prevented by this vaccine.

TEEN CHILDBEARING TRENDS

Joyce A. Martin et al. of the CDC report in "Births: Final Data for 2004" (National Vital Statistics Reports, September 29, 2006) that even though birthrates for unmarried women had risen in recent years, the birthrates among unmarried teens had dropped from a high of 45.8 per 1,000 women in 1994 to 34.7 per 1,000 women in 2004. Among girls aged fifteen to seventeen, the birthrate dropped from a high of 31.7 per 1,000 women in 1994 to 20.1 per 1,000 women in 2004. (See Figure 5.2.) Among young women aged eighteen to nineteen years, the birthrate dropped from a high of 69.1 per 1,000 in 1994 to 57.7 in 2004. In "Can Changes in Sexual Behaviors among High School Students Explain the Decline in Teen Pregnancy Rates in the 1990s?" (Journal of Adolescent Health, August 2004), John S. Santelli et al. find that both later ages at first intercourse and improved contraceptive practice contributed equally to the decline in pregnancy rates over the period.

According to Martin et al., available data by race show that the greatest percentage decline in births between 1991 and 2004 was among African-American
teens aged fifteen to nineteen, down from 118.2 births per 1,000 in 1991 to 63.1 in 2004. (See Table 5.3.) The Hispanic rate in this age group in 2004 was higher, at 82.6 births per 1,000, even though it had declined from the 1991 rate of 104.6. Non-Hispanic white teens fifteen to nineteen years old had a birthrate of 26.7 in 2004, down from 43.4 in 1991. The rate for Native American teens dropped from 84.1 in 1991 to 52.5 in 2004, and for Asian and Pacific Islander teens, from 27.3 in 1991 to 17.3 in 2004.

cData for persons of Hispanic origin are included in the data for each race group according to the mother's reported race.

dIncludes all persons of Hispanic origin of any race.

Notes: Race and Hispanic origin are reported separately on birth certificates. Persons of Hispanic origin may be of any race. Race categories are consistent with the 1977 Office of Management and Budget (OMB) standards. Fifteen states reported multiple race data for 2004. The multiple race data for these states were bridged to the single-race categories of the 1977 OMB standards for comparability with other states.

Consequences for Teen Mothers and Their Children

Teenage mothers and their babies face more health risks than older women and their children. Teenagers who become pregnant are more likely than older women to suffer from pregnancy-induced hypertension and eclampsia (a life-threatening condition that sometimes results in convulsions and/or coma). Teenagers are more likely to have their labor induced, and an immature pelvis can cause prolonged or difficult labor, possibly resulting in bladder or bowel damage to the mother, infant brain damage, or even death of the mother and/or child.

Even though most health risks are similar for children born to teenage and older mothers, teenage mothers may have a higher prevalence of certain risk factors. For example, in Health, United States, 2006 (http://www.cdc.gov/nchs/data/hus/hus06.pdf), the CDC notes that teenagers had high rates of smoking during pregnancy (10.5% for fifteen- to seventeen-year-olds and 16% for eighteen- to nineteen-year-olds) in 2004 and that smokers are nearly twice as likely to have low birth weight babies as nonsmokers. The HHS finds in the fact sheet "Preventing Infant Mortality" (January 13, 2006, http://www.hhs.gov/news/factsheet/infant.html) that teenagers in general are at a higher risk of having low birth
weight babies. Furthermore, in "Youngest Mothers' Infants Have Greatly Elevated Risk of Dying by Age One" (Perspectives on Sexual and Reproductive Health, January-February 2003), Michael Klitsch indicates that babies born to adolescents have a greater risk of dying between one and twelve months after birth.

Few teenage mothers are ready for the emotional, psychological, and financial responsibilities and challenges of parenthood. Becoming a parent at a young age usually cuts short a teenage mother's education, limiting her ability to support herself and her child. According to Sandra L. Hofferth, Lori Reid, and Frank L. Mottj, in "The Effects of Early Childbearing on Schooling over Time" (Family Planning Perspectives, November-December 2001), women who gave birth as teens in the early 1990s had only a 65% probability of graduating from high school, and only a 29% probability of completing some college. Additionally, Susheela Singh et al., in "Socioeconomic Disadvantage and Adolescent Women's Sexual and Reproductive Behavior: The Case of Five Developed Countries" (Family Planning Perspectives, November-December 2001), note that 40% of American women aged twenty to twenty-four who gave birth before age twenty had an income of less than 149% of the federal poverty guideline.

The children of teen mothers face consequences as well. In Playing Catch-Up: How Children Born to Teen Mothers Fare (January 2005, http://www.teenpregnancy.org/works/pdf/PlayingCatchUp.pdf), Elizabeth Terry-Humen, Jennifer Manlove, and Kristin Moore examine data on kindergarteners to determine the relationship between the age a woman has a child and how her child does in several key areas: cognition and knowledge, language and communication skills, approaches to learning, emotional well-being and social skills, and physical well-being and motor development. The researchers find that children born to mothers aged seventeen or younger had lower general knowledge scores and language and communication skills, compared with children born to mothers aged twenty or older. Children's approaches to learning, physical well-being, and emotional development, as well as their social skills and emotional well-being, were relatively unaffected by maternal age. In sum, Terry-Humen, Manlove, and Moore state, "Children born to mothers aged 17 and younger began kindergarten with lower levels of school readiness…. The children born to mothers in their 20s clearly outperformed those whose mothers were still teenagers at time of birth, and the most consistent and pronounced differences were observed when comparing children born to mothers aged 17 and younger to those children born to mothers aged 22-29."

In 1996 President Bill Clinton signed into law the Personal Responsibility and Work Opportunity Reconciliation Act, which abolished the sixty-year-old Aid to Families with Dependent Children program and created the Temporary Assistance for Needy Families (TANF) block grant program. To be eligible for TANF benefits, unmarried minor parents are required to remain in high school or its equivalent and to live with a parent or in an adult-supervised setting. One provision in the law allows for the creation of second-chance homes for teen parents and their children. These homes require that all residents either enroll in school or participate in a job-training program. They also provide parenting and life-skills classes, as well as counseling and support services.

Adolescent Fathers

According to the Child Trends Databank, in "Teen Births" (January 2007, http://www.childtrendsdatabank.org/pdf/13_PDF.pdf), in 2004 fifteen- to nineteen-year-old males had a birthrate of 17 per 1,000, down from a high of 24.7 in 1991. This rate was substantially lower than the 2004 rate for teenage girls of 41.1 per 1,000. The rate was higher for African-American male teens (32.7) than for white male teens (14.3); data for Hispanic male teens was unavailable. The difference between male adolescent and female adolescent birthrates is due in part to the fact that many teen mothers have older partners, as well as to the underreporting of information about fathers on birth certificates. In 2003 Facts at a Glance (November 2003, http://www.childtrends.org/Files/FAAG2003.pdf), Child Trends reports that 38% of births to mothers aged eighteen and younger were to fathers four or more years older than the mother. In some cases teen mothers have been sexually abused by their older partners.

Such studies alert officials who design programs for the prevention of pregnancy and STDs to the need to pay attention not only to preadolescent and adolescent males but also to older males who are partners of teenage girls. Because these men are typically out of the public school system, officials agree that programs must be broader in scope.

TEEN ABORTION

The CDC reports that in 2003, 848,000 abortions were performed; the year before, 854,000 had been performed. (See Table 5.4.) The Alan Guttmacher Institute conducted a survey and estimated that a much higher number of abortions had been performed in 2003—almost 1.3 million. As Table 5.4 shows, the rate of abortions per 100 live births has decreased from a high of 35.9 in 1980 to 24.1 in 2003. Girls under fifteen years old have the highest rate of abortions (83 per 100 live births) followed by teens aged fifteen to nineteen (37.4 per 100 live births). All other age groups have lower rates of abortion. For all age groups, African-Americans have the highest abortion rate of any race or ethnic group (49.1 per 100 live births), followed by Hispanics (22.8 per 100

aIn 1998 and 1999, Alaska, California, New Hampshire, and Oklahoma did not report abortion data to CDC. For comparison, in 1997, the 48 corresponding reporting areas reported about 900,000 legal abortions.

bIn 2000, 2001, and 2002, Alaska, California, and New Hampshire did not report abortion data to CDC.

cIn 2003, California, New Hampshire, and West Virginia did not report abortion data to CDC.

dNo surveys were conducted in 1983, 1986, 1989, 1990, 1993, 1994, 1997, 1998, 2001, or 2002. Data for these years were estimated by interpolation.

eFor calculation of ratios by each characteristic, abortions with characteristic unknown were distributed in proportion to abortions with characteristic known.

fFor 1989 and later years, white race includes women of Hispanic ethnicity.

gBefore 1989, black race includes races other than white.

hReporting area increased from 20-22 states, the District of Columbia (DC), and New York City (NYC) in 1991–1995 to 27 states, DC and NYC, with 12 additional states reporting to CDC, but with more than 15% unknowns, and thus excluded from analysis, for 2002 and 2003. California, Florida, Illinois, and Arizona, states with large Hispanic populations, do not report Hispanic ethnicity.

iFor 1973–1975, data indicate number of living children.

jFor 1975, data refer to four previous live births, not four or more. For five or more previous live births, the ratio is 47.3.

kFor calculation of percent distribution by each characteristic, abortions with characteristic unknown were excluded.

Notes: The number of areas reporting adequate data (less than or equal to 15% missing) for each characteristic varies from year to year.

Source: "Table 16. Legal Abortions and Legal Abortion Ratios, by Selected Patient Characteristics: United States, Selected Years 1973–2003," in Health: United States, 2006, with Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, 2006, http://www.cdc.gov/nchs/data/hus/hus06.pdf (accessed February 25, 2007)

Number of legal abortions reported in thousands

Centers for Disease Control and Prevention (CDC)

616

855

1,298

1,329

1,429

1,211

862

857

853

854

848

Alan Guttmacher Instituted

745

1,034

1,554

1,589

1,609

1,359

1,315

1,313

1,303

1,293

—

Abortions per 100 live birthse

Total

19.6

27.2

35.9

35.4

34.4

31.1

25.6

24.5

24.6

24.6

24.1

Age

Under 15 years

123.7

119.3

139.7

137.6

81.8

66.4

70.9

70.8

74.4

75.3

83.0

15-19 years

53.9

54.2

71.4

68.8

51.1

39.9

37.5

36.1

36.6

36.8

37.4

20-24 years

29.4

28.9

39.5

38.6

37.8

34.8

31.6

30.0

30.4

30.3

30.0

25-29 years

20.7

19.2

23.7

21.7

21.8

22.0

20.8

19.8

20.0

20.0

19.5

30-34 years

28.0

25.0

23.7

19.9

19.0

16.4

15.2

14.5

14.7

14.8

14.4

35-39 years

45.1

42.2

41.0

33.6

27.3

22.3

19.3

18.1

18.0

18.0

17.3

40 years and over

68.4

66.8

80.7

62.3

50.6

38.5

32.9

30.1

30.4

31.0

29.3

Race

Whitef

32.6

27.7

33.2

27.7

25.8

20.3

17.7

16.7

16.5

16.4

16.5

Black or African Americang

42.0

47.6

54.3

47.2

53.7

53.1

52.9

50.3

49.1

49.5

49.1

Hispanic originh

Hispanic or Latino

—

—

—

—

—

27.1

26.1

22.5

23.0

23.3

22.8

Not Hispanic or Latino

—

—

—

—

—

27.9

25.2

23.3

23.2

23.7

23.4

Marital status

Married

7.6

9.6

10.5

8.0

8.7

7.6

7.0

6.5

6.5

6.5

6.3

Unmarried

139.8

161.0

147.6

117.4

86.3

64.5

60.4

57.0

57.2

57.0

53.8

Previous live birthsi

0

43.7

38.4

45.7

45.1

36.0

28.6

24.3

22.6

26.4

23.3

22.7

1

23.5

22.0

20.2

21.6

22.7

22.0

20.6

19.4

18.0

19.4

19.0

2

36.8

36.8

29.5

29.9

31.5

30.6

29.0

27.4

25.5

27.9

27.1

3

46.9

47.7

29.8

18.2

30.1

30.7

29.8

28.5

26.4

29.1

28.3

4 or morej

44.7

43.5

24.3

21.5

26.6

23.7

24.2

23.7

21.9

23.6

23.4

Percent distributionk

Total

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

Period of gestation

Under 9 weeks

36.1

44.6

51.7

50.3

51.6

54.0

57.6

58.1

59.1

60.5

60.5

9-10 weeks

29.4

28.4

26.2

26.6

25.3

23.1

20.2

19.8

19.0

18.4

18.0

11-12 weeks

17.9

14.9

12.2

12.5

11.7

10.9

10.2

10.2

10.0

9.6

9.7

13-15 weeks

6.9

5.0

5.1

5.9

6.4

6.3

6.2

6.2

6.2

6.0

6.2

16-20 weeks

8.0

6.1

3.9

3.9

4.0

4.3

4.3

4.3

4.3

4.1

4.2

21 weeks and over

1.7

1.0

0.9

0.8

1.0

1.4

1.5

1.4

1.4

1.4

1.4

Previous induced abortions

0

—

81.9

67.6

60.1

57.1

55.1

53.7

54.7

55.5

55.3

55.3

1

—

14.9

23.5

25.7

26.9

26.9

27.1

26.4

25.8

25.8

25.7

2

—

2.5

6.6

9.8

10.1

10.9

11.5

11.3

11.0

11.3

11.2

3 or more

—

0.7

2.3

4.4

5.9

7.1

7.7

7.6

7.7

7.6

7.8

live births) and whites (16.5 per 100 live births). As Figure 5.3 and Figure 5.4 show, the abortion rates for teens have declined dramatically since the late 1980s, as have the pregnancy and birthrates.

States have varying laws on parental involvement in minors' abortion decisions. In "An Overview of Abortion Laws" (April 1, 2007, http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf), the Alan Guttmacher Institute reports that sixteen states and the District of Columbia require no parental involvement in minors' abortions. Thirty-five states require some parental involvement: twenty-four require parental consent, and thirteen require parental notification (Oklahoma and Utah require both parental involvement and consent).

HOMOSEXUALITY

Just the Facts about Sexual Orientation and Youth: A Primer for Principals, Educators, and School Personnel (2007, http://www.apa.org/pi/lgbc/publications/justthefacts.html), a pamphlet for school personnel put together by several organizations, including the American Academy of Pediatrics, the American Psychological Association, and the National Education Association, stresses that sexual orientation is one aspect of the identity of adolescents—not a mental disorder. According to the publication, sexual orientation is developed across a lifetime and along a continuum; in other words, teens are not necessarily simply homosexual or heterosexual, but may feel varying degrees of attraction to people of both genders. The pamphlet emphasizes that gay, lesbian, and bisexual adolescents face prejudice and discrimination that negatively affect their educational experiences and emotional and physical health. Their legitimate fear of being hurt as a result of disclosing their sexuality often leads to a feeling of isolation. All these factors account for lesbian, gay, and bisexual adolescents' higher rates of emotional distress, suicide attempts, risky sexual behavior, and substance use. The publication underscores the need for school personnel to be as open and accepting as possible to support these adolescents.

STD AND PREGNANCY PREVENTION PROGRAMS FOR TEENS

Abstinence

In response to the growing concern about out-of-wed-lock births and the threat of AIDS, several national youth organizations and religious groups began campaigns in the early and mid-1990s to encourage teens to sign an abstinence pledge—a promise to abstain from sexual activity until marriage. According to the National Institutes of Health news release "Virginity Pledge Helps Teens Delay Sexual Activity" (January 5, 2001, http://www.nichd.nih.gov/news/releases/virginity.cfm), by 1995, 2.5 million teens had taken the "virginity pledge." Debra Hauser,
the vice president of Advocates for Youth, indicates in Five Years of Abstinence-Only-until-Marriage Education: Assessing the Impact (2004, http://www.advocatesforyouth.org/publications/stateevaluations.pdf) that in 1996 the federal government committed $250 million over the next five years to fund state initiatives to promote abstinence as Title V of the Social Security Act. Even though only eleven states made results of their evaluations of the effectiveness of these programs public, Hauser states that Advocates for Youth examined these evaluations and found that the programs "showed few short-term benefits and no lasting, positive impact…. No program was able to demonstrate a positive impact on sexual behavior over time."

The Bush administration placed a new stress on abstinence among teens. According to the White House report Working toward Independence (February 2002, http://www.whitehouse.gov/news/releases/2002/02/welfare-reform-announcement-book.pdf), an overview of President George W. Bush's suggested plan for welfare reform, "the goal of Federal policy should be to emphasize abstinence as the only certain way to avoid both unintended pregnancies and STDs." According to the HHS's 2008 Budget in Brief (2007, http://www.hhs.gov/budget/08budget/2008BudgetInBrief.pdf), $191 million was allocated for abstinence education in fiscal year 2008, an increase of $28 million over fiscal year 2007.

Regardless, the CDC finds that in 2005 approximately one-third of high school students (33.9%) were sexually active at the time of being surveyed—34.6% of females and 33.3% of males. (See Table 5.1.) Younger students were less likely to be currently sexually active than were older students. However, almost half of all students (46.8%) had ever had sexual intercourse; 63.1% of high school seniors had.

In this context, abstinence-only education will do little to prevent teen pregnancy or the spread of STDs. As John S. Santelli et al. state, in "Abstinence and Abstinence-Only Education: A Review of U.S. Policies and Program" (Journal of Adolescent Health, January 2006), "Although abstinence is a healthy behavioral option for teens, abstinence as a sole option for adolescents is scientifically and ethically problematic…. We believe that abstinence-only education programs, as defined by federal funding requirements, are morally problematic, by withholding information and promoting questionable and inaccurate opinions. Abstinence-only programs threaten fundamental human rights to health, information, and life."

Sex and STD/HIV Education in Schools

As of July 2007, thirty-five states and the District of Columbia required schools to provide education on HIV/AIDS and other STDs, although in all cases parents were allowed to remove their children from sex education classes. (See Table 5.5.) Twenty-two states required schools to stress the importance of abstinence in STD and HIV/AIDS education, and ten states required abstinence to be covered. Fourteen states required schools to teach students about contraception, but none required that it be stressed.

According to the CDC, in "Youth Risk Behavior Surveillance—United States, 2005" (Morbidity and Mortality Weekly Report, June 9, 2006), 87.9% of all students were taught about AIDS or HIV in school in 2005, compared with 91.5% in 1997. As HIV/AIDS is increasingly common among young people, the declining percentages of students who learn about the disease in school is problematic.

TABLE 5.5

State sex and STD/HIV education policy, July 2004

State

Sex education

STD/HIV education

Parental role

Mandated

If taught, content required

Mandated

If taught, content required

Consent required

Opt-out permitted

Abstinence

Contraception

Abstinence

Contraception

aParents' removal of student must be based on religious or moral beliefs.

bIn AZ, MT, NY and PA, opt-out is only permitted for STD education, including instruction on HIV; in AZ, parental consent is required only for sex education.

cIL has a broad set of law mandating general health education, including abstinence; a more specific second law requires a school district that provides sex education to stress abstinence and to provide statistics on the efficacy of condoms as HIV/STD prevention.

dLocalities may override state requirements for sex education topics, including abstinence; state prohibits including material that "contradicts the required components."

eAbstinence is taught within state-mandated character education.

fState prohibits teachers from responding to students' spontaneous questions in ways that conflict with the law's requirements.

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Teen Pregnancy

Encyclopedia of Children and Childhood in History and Society
COPYRIGHT 2004 The Gale Group Inc.

Teen Pregnancy

Using adolescent birth rates to measure teen pregnancy, adolescent parenthood has been a fairly common experience throughout American history. (It is nearly impossible to gain an accurate measure of teen pregnancy rates over time, because not all pregnancies result in births.) The most recent American teen birth rate of approximately 51.1 births per 1,000 adolescent females is consistent with historical trends and matches the 1920 figure. Nonetheless, since the 1970s, American politicians, policy makers, and social critics have condemned the perceived "epidemic of teenage pregnancy." This label reveals that critics have little knowledge about the incidence of teen pregnancy and parenthood in America's past.

From colonial times through the late nineteenth century, the vast majority of Americans had chosen to marry and have children by their early to mid-twenties. Marriage and parenthood was a rational choice for people living in a society dependent on family production. Race, ethnicity, class, and region could influence individual circumstances, with rural areas experiencing the lowest age at marriage. Few people worried about teen pregnancy as long as the expecting mother married before giving birth. There was strong social pressure to marry before becoming a parent, but the high number of babies born less than nine months after marriage ceremonies shows that many young couples taking their marriage vows were already expecting a child. State codes outlining minimum-age-at-marriage laws followed English common law that permitted girls as young as twelve to marry without parental consent.

The ability to bear children generally established the move from childhood to adulthood for most females. The capacity to do physical labor marked the change for boys from childhood dependence to a state of semi-dependence known as youth. For males, marriage marked full adult independence and its associated responsibilities. Physical capacities and life circumstance set the dividing line between childhood and adulthood, not age. Poor diet and common childhood illnesses delayed physical maturity for many. The majority of girls did not reach menarche (and their ability to have children) until sixteen or seventeen years of age. Many boys assumed strenuous jobs early in their adolescence, but few could earn enough to support a family until their early to mid-twenties. This combination of biological, social, and economic factors limited pregnancy and parenthood for most teens.

By 1900, things began to change. The move to an industrial economy had radically changed everyday life for many Americans. Improved health conditions and better economic opportunities for young males in the Progressive Era encouraged a growing number of couples to marry and become parents at younger ages, in their teens and early twenties. Interestingly, this trend toward early marriage and parenthood ran counter to the social definition of adolescence that had become increasingly popular among urban middle-class families. Since the 1820s, a growing number of middle-class parents had been sending their adolescent children to high schools. Advocates of the urban-middle-class-family ideal maintained that adolescence was a distinct period of life separate from adult responsibilities. They encouraged parents to leave their teenaged children in school instead of sending them to work or allowing them to marry.

In 1904, G. Stanley Hall formally defined the broad psychological and physiological parameters of modern adolescence in his two volume work, Adolescence: Its Psychology and Its Relations to Physiology, Anthropology, Sociology, Sex, Crime, Religion, and Education. Hall concluded that the teen years were a time of unavoidable physiological and psychological turmoil. While it was normal for teens to think about sex, Hall cautioned that adolescents were too immature, both physically and psychologically, to engage in sexual intercourse or become parents.

Many child welfare reformers agreed. New child labor laws, compulsory education legislation, the establishment of juvenile courts, efforts to control teen sexuality, and a myriad of other age-specific policies reflected new social attitudes defining modern adolescence. A growing number of teens, however, resisted the new restrictions on their autonomy. In 1900, less than 1 percent of males and 11 percent of females fourteen through nineteen years of age were ever married. During the next six decades the age of first marriage and sub-sequent parenthood continued to fall for both males and females. By 1950, the median age at first marriage was down to 22.8 for males and 20.3 for females. In the 1930s the Great Depression temporarily slowed the trend, but the postwar years saw a dramatic rise in early marriage and teen pregnancy rates. The 1940s, 1950s, and 1960s included the twentieth century's highest teen birth rates (respectively 79.5, 91.0, and 69.7 per thousand). By 1960, nearly one-third of American females had their first child before reaching age twenty.

The 1970s, 1980s, and 1990s reversed this trend. In the face of rising divorce rates, more college graduates, and reliable birth control, growing numbers of young people chose to delay marriage or not to marry at all. At the same time, the average age of menarche dropped to twelve, with some girls as young as eight experiencing menstruation. Many Americans ignored the rising age of marriage, and instead focused on changes in the incidence of unwed motherhood. By the 1990s, almost 25 percent of all babies were born to unmarried women. Teen mothers gave birth to only one-third of these infants, but the fact that black and Hispanic teens were more likely to have children outside of marriage than their white counterparts gained public attention. Furthermore, before 1970 the majority of unwed mothers gave up their babies for adoption. By the 1990s, nine of every ten teen mothers chose to keep their children and, at least for the immediate future, remain unmarried.

After 1970, rising concerns about teen pregnancy and parenthood became mixed with a variety of crucial social, economic, and political shifts. A new wave of immigration spurred by the 1965 Immigration Act increased American diversity. Changes in the nation's racial policies and practices grounded in the civil rights movement became part of federal law. Legal debates over access to abortion often centered on teens. Economic shifts fostered by the move from an industrial to a service- and information-based economy created new social problems. To many critics, unmarried teen mothers became symbols of American immorality and the growing Aid to Families with Dependent Children (AFDC) welfare program. As Hall had theorized decades earlier, teen pregnancy and parenthood, both inside and outside of marriage, seemed unacceptable and a modern social problem.

In 1996, Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act. This new law discontinued AFDC, included incentives for using implanted birth control, and placed restrictions on federal assistance to unwed teen mothers. To supporters, one of the keys to "changing welfare as we know it" was to end federal assistance to unwed teen mothers. Teen birth rates have continued to decline, but the reasons are not clear. It appears that young people, as they have done throughout American history, are making choices about parenthood for themselves.

See also:Adoption in the United States; Aid to Dependent Children; Dependent Children; Menarche; Parenting; Sexuality; Teenage Mothers in the United States.

bibliography

Gordon, Linda. 1994. Pitied but Not Entitled: Single Mothers and the History of Welfare.New York: Free Press.

Lindenmeyer, Kriste. 2002. "For Adults Only: The Anti-Child Marriage Campaign and Its Legacy." In Politics and Progress: American Society and the State since 1865, ed. Andrew Kersten and Kriste Lindenmeyer. Westport, CT: Praeger.

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Bellotti v. Baird

Encyclopedia of Children and Childhood in History and Society
COPYRIGHT 2004 The Gale Group Inc.

Bellotti v. Baird

In Bellotti v. Baird (Bellotti II), the Supreme Court addressed the issue of whether a dependent, unmarried minor can be required to obtain parental consent before undergoing an abortion. In a decision that recognized that minors can possess the competency and maturity to make the important decision of whether to obtain an abortion, the Court ruled that a state law can require a pregnant, unmarried minor to obtain parental consent for an abortion if the law also provides a bypass procedure that allows her to obtain judicial permission for the abortion without parental notification.

The 1974 Massachusetts law in question required an unmarried, pregnant minor to provide proof of her consent and her parents' consent to obtain an abortion. If either or both of her parents withheld consent, the young woman could obtain a judicial order to permit her to have an abortion. Alleging that the law created an undue burden for minors seeking abortions, opponents of the law brought a "test-case" class-action suit in the Federal District Court of Massachusetts to enjoin the operation of the statute. This legal action reached the U.S. Supreme Court in 1976, but the Court declined to consider the merits of the case because of a procedural error. Instead, the Supreme Court vacated the judgment of the District Court and remanded the case for a final determination of the statute's meaning by the Supreme Judicial Court of Massachusetts.

The case again reached the U.S. Supreme Court in 1979, at which time the Court fully addressed the issue of whether the law's parental consent requirement placed an undue burden on an unmarried, pregnant minor seeking an abortion. The Court stated that persons under age eighteen are not without constitutional protection; however, their constitutional rights and individual liberty must be balanced against considerations such as a minor's possible inability to make an informed decision and the important parental role of child rearing. Although the Court recognized that parental advice and consent could be important in helping a minor decide whether she should obtain an abortion, in an 8-1 decision, the Court invalidated the Massachusetts statute.

As Robert H. Mnookin and D. Kelly Weisberg have suggested, Justice Powell's plurality opinion sets forth guidelines to assist states in determining the extent to which a state can permissibly limit a minor's right to an abortion. According to the decision in Bellotti v. Baird, a state can require a minor to obtain consent to undergo an abortion, but it cannot solely require parental consent. Instead, the law must provide an alternative to parental consent–a "bypass" procedure. This procedure must satisfy four requirements: first, the minor must be permitted to demonstrate to the judge that she is mature and adequately well-informed to make the abortion decision with her physician and without parental consent; second, if she cannot demonstrate the requisite maturity, she must be permitted to convince the judge that the abortion would nonetheless be in her best interest; third, the bypass procedure must assure her anonymity, and; fourth, the bypass procedure must be sufficiently expedient to allow her to obtain the abortion.

See also:Adolescence and Youth; Children's Rights; Law, Children and the; Teenage Mothers in the United States.

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Teenage Pregnancy

Encyclopedia of Public Health
COPYRIGHT 2002 The Gale Group Inc.

TEENAGE PREGNANCY

In the United States, 900,000 adolescents (fifteen-to nineteen-year-olds) became pregnant in 1996. While this was 15 percent lower than in 1994, it is still higher than any other developed country. There are twice as many teenage pregnancies in the United States each year as there are in England, Wales, or Canada, and eight times as many as in Japan. These figures include live births (accounting for approximately half of the total of 900,000), induced abortions, and fetal losses due to miscarriages and still births.

In 1996, the pregnancy rate was twice as high among non-Hispanic black and Hispanic teens as among non-Hispanic white teens. By 2003, the under-18 Hispanic and non-Hispanic black population will be greater than 50 percent of the adolescent population. These figures are important in planning pregnancy-prevention programs.

Teen pregnancy is one serious consequence of early initiation of sexual activity. Other serious consequences include an increased likelihood of late or no prenatal care, unattended births, reduced educational attainment, and decreased employment opportunities. Infants of teenage mothers are at greater risk of low birth weight and increased infant mortality. Thirteen percent of infants born to 15 year olds have a low birth weight, compared to 7 percent of infants born to mothers in their twenties. Infants of mothers 13 to 14 years old have an infant mortality rate of 17 per 1000 live births, compared to the rate of 10 per 1000 live births for those 15 to 19 years old, and a rate of only 4.5 per 1000 live births for all mothers in the United States. Children of teenage mothers are more likely to perform poorly in school, more likely to drop out of school, and less likely to attend college. Overall problems related to teen pregnancies cost taxpayers an estimated $7 billion per year.

After three decades of steady increases, the proportion of teenagers 15 to 19 years old who were sexually active decreased by 50 percent during the mid 1990s. In addition, condom use at first intercourse increased from 18 percent in 1975 to 54 percent in 1995.

Socioeconomic factors and limited life options, rather than ethnic or cultural background, place many youth at higher risk for unintended pregnancy. Early attempts at preventing teen pregnancies often ignored the complex relationship between development, environment, and behavior. Neither those programs that focus on increasing knowledge, nor abstinence-only programs have been effective in reducing the rate of unintended pregnancies. Adolescent behaviors are shaped by the desire to broaden horizons, interact with peers, or try out adult roles and behaviors. If early sexual behavior is the only perceived option to achieve these objectives, teens may well choose it.

As our society moves forward, a more comprehensive approach to reducing adolescent pregnancy is needed. Many risk behaviors, including early and unprotected intercourse, are linked and share common motivations. Programs designed to prevent pregnancy need to address these other behaviors as well. A variety of life choices need to be available for teens, and programs need to address real economic barriers if the unintended teen pregnancy rate in the United States is to be reduced.

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